McAnena O J, Heald R J, Lockhart-Mummery H E
Department of Surgery, Basingstoke District Hospital, Hampshire, United Kingdom.
Surg Gynecol Obstet. 1990 Jun;170(6):517-21.
Eighty-one patients underwent anterior resection with curative (n = 57) or palliative (n = 24) intent for tumors below 7 centimeters from the anal verge. If a right angled clamp could be applied below the tumor at operation after full mobilization of the mesorectum and rectum, the procedure was performed in preference to abdominoperineal excision. The mean follow-up time was 4.8 years. Of the curative group, 26 had lesions within 5 centimeters of the anal verge. Thirty-one per cent were Dukes' A; 37 per cent, B, and 32 per cent, C lesions. The margin of distal clearance ranged from 2 to 35 millimeters. In five patients, squamous mucosa was observed in the distal doughnut. Serious postoperative complications occurred in 17 per cent of the curative series, one-half of which occurred within the first two years of the study period. In six patients, the temporary colostomy has not been closed. The incidence of local recurrence in the curative series was 3.5 per cent, and the over-all survival rate was 81 per cent at five years. Full continence was achieved within two years of closure of the colosomy in 85 per cent of the patients. In the palliative group, 11 of the 19 patients had temporary colostomies and 80 per cent were continent within six months of operation. The technique of total mesorectal excision and sphincter preservation by stapled coloanal anastomosis in the treatment of carcinomas of the lower one-third of the rectum may be an alternative to abdominoperineal excision. The final decision in such instances is made intraoperatively. The operative and functional results are satisfactory, but it is difficult to anticipate the patients who will not do well by preoperative criteria. Even in palliative procedures, low anterior resections provided satisfactory continence. Serious postoperative complications were more likely to occur if full mobilization of the splenic flexture was not routinely performed.
81例患者因距肛缘7厘米以下的肿瘤接受了根治性（n = 57）或姑息性（n = 24）的前切除术。如果在直肠系膜和直肠充分游离后手术时能在肿瘤下方应用直角钳，则优先进行该手术而非腹会阴联合切除术。平均随访时间为4.8年。在根治性治疗组中，26例患者的病变位于距肛缘5厘米以内。31%为Dukes' A期病变；37%为B期，32%为C期病变。远端切缘范围为2至35毫米。在5例患者的远端标本环中观察到鳞状黏膜。根治性治疗组中17%发生了严重的术后并发症，其中一半发生在研究期的头两年内。6例患者的临时结肠造口尚未关闭。根治性治疗组的局部复发率为3.5%，5年总生存率为81%。85%的患者在结肠造口关闭后两年内实现了完全控便。在姑息性治疗组中，19例患者中有11例行临时结肠造口术，80%的患者在术后6个月内实现了控便。通过吻合器结肠肛管吻合术进行全直肠系膜切除和保留括约肌技术治疗直肠下三分之一癌可能是腹会阴联合切除术的一种替代方法。在这种情况下的最终决定在术中做出。手术和功能结果令人满意，但很难根据术前标准预测哪些患者预后不佳。即使在姑息性手术中，低位前切除术也能提供令人满意的控便效果。如果不常规进行脾曲的充分游离，严重术后并发症更有可能发生。
